Friday, September 24, 2010

MaxilloMandibular Sugery very successful treatment for sleep apnea. TONGUE REDUCTION AS AN ALTERNATIVE.

A recent article "Maxillomandibular advancement for the treatment of obstructive sleep apnea: a systematic review and meta-analysis." in Sleep Medicine Review (abstract below) looked at the success of MaxilloMandibular (MMA) surgery for treating sleep apnea. The study concluded that "conclude that MMA is a safe and highly effective treatment for OSA."

This is very good news for patients who want a permanent treatment cure. Complication rates for this extensive surgery were relatively low. The report also stated " Younger age, lower preoperative weight and AHI, and greater degree of maxillary advancement were predictive of increased surgical success" again all excellent news. The The mean apnea-hypopnea index (AHI) decreased from 63.9/h to 9.5/h following surgery however an AHI of less than 5 is considered a cure. 86% were considered successful and 43% were considered cured.

If you are contemplating MMA surgery it is probably best to begin with an Oral Appliance. If complete resolution of apnea is obtained that jaw position will serve as a surgical landmark to insure success. Cure rates can be dramatically increased by using oral appliance titration end points to determine degree of advancement. The TAP 1 appliance is probably the most efficacious apppliance to determine ideal jaw position due to its ability to advance the lower jaw past maximum voluntary protrusion position.

MANY PATIENTS WHO CONSIDER SURGICAL CORRECTION WILL OPT TO CONTINUE WITH A COMFORTABLE ORAL APPLIANCE AFTER TITRATION. THIS AVOIDS ALL SURGICAL RISK. THOSE PATIENTS WHO ELECT SURGERY HAVE AN INCREASED PROBABILITY OF SUCCESS AND CURE.

Base of the Tongue reduction surgery has also shown positive results though the procedure can be brutal. Reduction of the base of the tongue with Somnoplasty (SEE ABSTACT BELOW) requires multiple surgeries but can achieve the same results and is far less brutal.

I have seen several patients who have done 1 or 2 somnoplasty procedures on the base of tongue and decided to use an oral appliance and they have all been easy to manage with appliances.

Stanford University Sleep Medicine Program, Stanford University School of Medicine, Stanford, CA, USA. jholty@stanford.eduAbstractThe reported efficacy of maxillomandibular advancement (MMA) for the treatment of obstructive sleep apnea (OSA) is uncertain. We performed a meta-analysis and systematic review to estimate the clinical efficacy and safety of MMA in treating OSA. We searched Medline and bibliographies of retrieved articles, with no language restriction. We used meta-analytic methods to pool surgical outcomes. Fifty-three reports describing 22 unique patient populations (627 adults with OSA) met inclusion criteria. Additionally, 27 reports provided individual data on 320 OSA subjects. The mean apnea-hypopnea index (AHI) decreased from 63.9/h to 9.5/h (p<0.001) following surgery. Using a random-effects model, the pooled surgical success and cure (AHI <5) rates were 86.0% and 43.2%, respectively. Younger age, lower preoperative weight and AHI, and greater degree of maxillary advancement were predictive of increased surgical success. The major and minor complication rates were 1.0% and 3.1%, respectively. No postoperative deaths were reported. Most subjects reported satisfaction after MMA with improvements in quality of life measures and most OSA symptomatology. We conclude that MMA is a safe and highly effective treatment for OSA.

Sleep Disorders Center, Department of Otorhinolaryngology, Head and Neck Surgery, University Hospital Mannheim, Germany. boris.stuck@hno.ma.uni-heidelberg.deAbstractIn recent years a considerable effort has been made to establish the use of different surgical techniques for the treatment of obstructive sleep apnea syndrome (OSAS). Nevertheless, treatment of hypopharyngeal obstruction due to tongue base hypertrophy remains in many ways an unsolved problem. The aim of this study was to evaluate the safety and efficacy of tongue base reduction with temperature-controlled radiofrequency volumetric tissue reduction in the treatment of OSAS. Twenty patients with OSAS and tongue base hypertrophy were treated with radiofrequency tissue ablation. An intensified treatment protocol was used, delivering 2,800 J per treatment session under local anesthesia. Two nights of polysomnography testing were performed before and after treatment. Daytime sleepiness, snoring and postoperative morbidity were assessed using questionnaires. Mean respiratory disturbance index (RDI) was reduced from 32.1 to 24.9/h after a mean of 3.4 treatment sessions. Six patients (33%) were cured after the procedure (reduction in RDI of > or = 50% and a postoperative RDI of < 15/h) and ten (55%) showed an improvement of > 20% in their RDI. Daytime sleepiness and snoring improved significantly. Peri- and postoperative morbidity was low; one severe complication occurred (tongue base abscess). We were able to achieve similar cure and responder rates to those reported in a recently published pilot study but with a reduced number of treatment sessions. We believe that this technique may improve patient acceptance and have beneficial cost implications.